Sickle Cell Form/Waiver - University of Texas at Dallas

RELEASE OF NEWBORN SCREENING RECORDS AUTHORIZATION FORMAthleteos Full Name:Athlete's Date of Birth:FuIl name of athlete's mother at time of athlete's birth:If athlete is under age 18:I, (name of parent or guardian), hereby authorize theTexas Department of State Health Services Newborn Screening Lab to release all newbomscreening results of my son/daughter to Dr. Robert Dimeff, the treating physician andrepresentative of The University of Texas at Dallas Athletic Department.Parent/guardian signature:Athletets signature:If athlete is age 18 or older:I, (name of athlete), hereby authorize the TexasDepartment of State Health Services Newborn Screening Lab to release all of my newbornscreening results to Dr. Robert Dimeff, the treating physician and representative of TheUniversity of Texas at Dallas Athletic Department.Athlete's signature:ATTENTION: Newborn Screening Lab, please fax results to: (972)-883-4496